The dual burden of being overweight and undernourished

Published 10:00 pm, Tuesday, November 18, 2008

We have been told -- all too often -- that rising obesity rates in the U.S. are the result of a toxic food environment. Not so.

All evidence suggests that obesity is the toxic consequence of a failing economic environment. The social and economic policies of the past two decades have created an obese and increasingly diabetic American underclass. The consequences of fiscal deregulation, spanning several previous administrations, will plague the health system for years to come.

We were told that obesity was genetically driven, much like height. Not so. Both obesity and diabetes follow a social gradient. Bodies do not lie. High body weight, an infallible index of lower social class among women, is associated with economic insecurity and social distress. The social gradient applies equally to geographic measures.

Upscale neighborhoods are lean; poor neighborhoods are more likely to be obese. Across King County, obesity rates range from a low of 5 percent to a high of 30 percent depending on ZIP code. Seattle real estate prices, a good index of area poverty or wealth, are a reliable predictor both of obesity and of diabetes-related deaths.

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We were told that obesity was the result of poor choices regarding fitness or diet. Not so. The carefully fostered illusion of freedom of choice disguises the fact that most people have none. Energy-dense foods, many of them nutrient poor, are good tasting, readily available, and cheap. Households selecting fast foods are typically accused of laziness, self-indulgence and moral failure. Few have thought to ask whether low-income households were simply making the only economic choices available.

Skyrocketing food prices have put the global obesity issue in a new and starker perspective. Speaking at the June 2008 High-level Conference on World Food Security in Rome, Margaret Chan, director general of the World Health Organization, said: "Food choices are highly sensitive to price. The first items to drop out of the diet are usually healthy foods -- fruit, vegetables, and high-quality sources of protein. ... Nutrient-poor staples are often the cheapest way to fill hungry stomachs." She reiterated those words at the June 2008 Pacific Health Summit in Seattle.

That declaration was directly based on research on diet quality and diet cost. Simply put, as incomes drop and food budgets shrink, food choices shift toward energy-dense refined grains, added sugars and fats. Whereas higher food spending does not guarantee a better diet, reducing spending below a certain minimum virtually ensures that the resulting diet will be energy-rich but nutrient-poor. Computer models, when driven by cost constraints only, consistently create diets similar to those consumed by the poor.

The obesity debate in the U.S. has steered clear of the complex issues of social class. Rather, much time has been spent on genetics, physiology, race/ethnicity, personal responsibility and freedom of choice. Attempts to improve dietary habits have stressed individual food choice behavior, psychosocial factors, self-efficacy and readiness to change. Official guidelines such as the 2005 Dietary Guidelines for Americans and USDA MyPyramid exhort consumers to "choose" healthful diets as opposed to unhealthy ones, somewhat like choosing chocolate over vanilla ice cream.

The issue of cost is never mentioned. Yet the key predictor of weight gain may not turn out to be sugar or fat, but simply low diet cost.

The issue of access to food sources is only now getting recognition. Minorities and the poor are at a disadvantage here: Poor neighborhoods attract fast food outlets and convenience stores as opposed to full-service supermarkets, an issue sometimes framed in terms of social justice.

However, given that many healthful foods have become luxury goods, their availability is driven by neighborhood buying power. It is a shame that many of the current strategies for obesity management are based not around alleviating poverty but around recommending high-cost foods to low-income people. That approach will not work in the U.S. or elsewhere.

The dual burden of undernutrition and overweight now faced by developing nations is another economic issue directly linked to poverty, food prices and diet costs.

The relation between food, incomes and health should once again become a priority for global public health. The major policy and political challenge for global nutrition is to ensure a supply of affordable healthy foods to all.